Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to properly investigate an allegation of resident-to-resident abuse involving two residents. One resident, who was cognitively intact and had a diagnosis of COPD, allegedly made a threatening statement to another resident, who was moderately cognitively impaired and had a diagnosis of major depressive disorder. The incident was reported by a medication aide after the resident receiving medication stated that their roommate had threatened them. The facility's investigation only included an interview with the resident who reported the threat and did not include interviews with other involved or cognitively intact residents, including the alleged perpetrator. The Registered Nurse Manager confirmed that the investigation was incomplete and that other residents should have been interviewed.